2025 CPT code 23397
Effective Date: N/A Surgery - Musculoskeletal System Feed
Muscle transfer, any type, shoulder or upper arm; multiple.
Modifiers may be applicable to indicate specific circumstances of the procedure, such as increased procedural services (modifier 22), multiple procedures (modifier 51), or distinct procedural services (modifier 59). Refer to current CPT guidelines for appropriate modifier usage.
Medical necessity must be established by documenting the functional impairment caused by the injury or condition, failed conservative treatments, and the expected functional improvement from the muscle transfer(s). The documentation should demonstrate how the procedure will improve the patient's quality of life.
The surgeon performs the entire procedure, including prepping the patient, dissecting the donor muscle, preparing the recipient site, transferring and fixing the muscle(s), irrigating the wound, stopping bleeding, and closing the incision(s).
In simple words: This procedure involves moving several muscles from another part of the body, like the leg, to the shoulder or upper arm. This is done to fix injuries that make it hard to use the arm or shoulder because the muscles there are damaged. The surgeon takes a muscle from the leg, moves it to the arm, and attaches it to the bone and the damaged muscle. This is done for each muscle being moved.
This procedure involves transferring multiple muscles from another location on the patient’s body to the shoulder or upper arm to treat injuries that impair upper extremity function due to damage to the muscles in the upper arm or shoulder. The surgeon dissects the donor muscle (e.g., gracilis muscle in the patient's thigh) and prepares the recipient site in the patient's shoulder or upper arm. The muscle is freed from the leg, brought to the arm, and positioned within the recipient site. It's then fixed into place by suturing one end to the remaining end of the damaged muscle and the other end to the bone. This is repeated for additional sites. Finally, the site is irrigated, bleeding is stopped, and the wounds are closed by suturing the layers of tissue together.
Example 1: A patient with a brachial plexus injury resulting in significant loss of shoulder and upper arm muscle function undergoes multiple muscle transfers to restore function., Following a traumatic avulsion of multiple rotator cuff muscles, a patient requires multiple muscle transfers to reconstruct the shoulder and regain arm movement., A patient with a history of multiple failed rotator cuff repairs undergoes multiple muscle transfers as a salvage procedure to address chronic shoulder dysfunction and pain.
Documentation should include the diagnosis necessitating the muscle transfer(s), the specific muscles transferred, the donor site(s), operative details, and any complications encountered. Pre- and postoperative imaging studies may also be included.
** Code 23395 should be used for a single muscle transfer in the shoulder or upper arm. The excision of any soft tissue tumors or radical resection of tumors should be reported separately.
- Specialties:Orthopedic Surgery, Plastic Surgery (when applicable)
- Place of Service:Ambulatory Surgical Center, Hospital - Inpatient or Outpatient, Physician's Office (depending on the complexity and patient's condition)